Evaluate breaches in the standard of care when determining whether or not there has been a Deviation in the Standard of Radiological Care When Utilizing Intravenous Contrast During Diagnostic Procedures (Radiocontrast, Dye, Gadolinium)

Answer the following questions to find out if the standard of care was followed for your case.

Was a thorough medical history obtained?YesNoAnswer unknownWhy is this important?All patients must be evaluated for predisposing risk factors before injection of contrast media. Evaluation may comprise detailed history and, if needed, physical examination and laboratory tests.(2006) 35 ECPDRD 4 164-169

Did the patient present with any predisposing risk factors? Why is this important?Answer this question Prior to administration of iodinated contrast, the patient must be screened and cleared of any risk factors. Predisposing risk factors include: •Previous reactions to iodinated contrast media • Any allergic and reactions (both to medications and seafood) •Age 60 years or over •History of diabetes, kidney disease, solitary kidney, pheochromocytoma, kidney or other transplant, or myeloma •Current use of any metformin-containing medications •Women of child-bearing age (pregnant or if they are breast-feeding). (2007) 62 ESEUJR S 26-32

Was a detailed medication history obtained? Why is this important?Answer this question Certain medications may need to be discontinued prior to the procedure. (2007) 62 ESEUJR S 33-37

Was the patient on metformin? Why is this important?Answer this question Metformin, an oral diabetes medicine that helps control blood sugar levels in patients with type II diabetes, requires renal clearance and accumulates in the blood in acute renal failure. Excessive levels of metformin have been known to cause lactic acidosis, which carries approximately a 50% fatality rate. Metformin should be withheld the morning of any procedure using intravenous or intra-arterial iodinated contrast and for at least 48 hours post procedure. (2010) 25 JPANEN 2 94-103

Was the patient’s kidney function evaluated before restarting metformin? Why is this important?Answer this question Because it may take up to 10 days for the estimated glomerular filtration rate (eGFR) to return to baseline, should contrast induced nephropathy occur, serum creatinine (SCr) should be obtained and kidney function evaluated before restarting metformin. (2010) 25 JPANEN 2 94-103

Were gadolinium contrast agents avoided in a pregnant patient? Why is this important?Answer this question Free iodide in radiographic contrast medium given to the mother has the potential to depress fetal/neonatal thyroid function. Neonatal thyroid function must be checked during the first week, if iodinated contrast media have been given during pregnancy. The contrast media safety committee considers this check mandatory. (2006) 60 ESEUJR 3 307-313

Was an informed consent obtained and documented? Why is this important?Answer this question The laws of most states require that physicians obtain informed consent before providing treatment. (2011) 23 EOMSCA 3 475-484

Were laboratory studies obtained prior to the procedure? Why is this important?Answer this question Because the incidence of contrast induced nephropathy is more likely in patients with chronic kidney disease, it is important to determine the patients' renal function prior to the administration of contrast media. (2007) 62 ESEUJR S 26-32

Were ionic contrasts avoided in patients with moderate to severe kidney disease? Why is this important?Answer this question The patients at highest risk for developing contrast induced acute renal failure are those with pre-existing renal impairment particularly when the reduction in renal function is secondary to diabetic nephropathy. (2006) 60 ESEUJR 3 307-313

Was intravenous contrast administered to a patient with renal disease? Why is this important?Answer this question Many patients have renal disease and co-morbidities that increase their risk for contrast-related renal failure. Since contrast material may be nephrotoxic it must be used with extreme caution in these patients. (2012) 31 JRADNU 4 120-129

Were preventive measures taken to avoid adverse reactions? Why is this important?Answer this question Prevention of contrast induced nephrotoxicity will require the clinician to take medically necessary precautionary steps. (2005) 16 EJVAIR 1 13-23

Were the patient’s vital signs recorded prior to the procedure? Why is this important?Answer this question Blood pressure, pulse rate and temperature need to be documented for all patients as this serves as a baseline during the procedure. (2007) 62 ESEUJR S 26-32

Was the patient prophylactically pre-medicated? Why is this important?Answer this question Premedication is generally reserved for patients with a history of a significant prior contrast reaction. Click here for additional information

Were there any extravasation injuries? Why is this important?Answer this question If the intravenous contrast is not administered properly it can result in extravasations of contrast material which might produce burning pain in the site, tenderness, edema, and erythema, blistering, sloughing of skin, and compartment syndrome. (2006) 35 ECPDRD 4 164-169

Was the contrast extravasation adequately managed? Why is this important?Answer this question Prevention is the ideal treatment for extravasation injuries. It is important to stop the intravenous infusion as soon as an extravasation is recognized. (2011) 36 JLHASU 12 2060-2065

What was the severity of the systemic adverse reaction? Why is this important?Answer this question Adverse systemic reaction to contrast media may range from very mild to anaphylaxis. It is vital for the clinician to recognize the early symptoms of an allergic reaction. (2006) 35 ECPDRD 4 164

Were the patient’s airway, breathing and circulation managed appropriately? Why is this important?Answer this question In the event of an allergic reaction, the administration of the intravenous contrast must be stopped immediately and appropriate emergency procedures implemented. (2004) 24 EIACNA 3 507-519

Was the patient resuscitated? Why is this important?Answer this question Administration of the intravenous contrast must be stopped immediately and appropriate emergency procedures must be implemented. The patient needs to be closely monitored. The period of monitoring will depend on type and amount of contrast used and also the nature of the reaction. Observations such as blood pressure, pulse and respiration must be commenced immediately. (2004) 24 EIACNA 3 507-519